First of all pure air containing plenty of oxygen. Therefore the sea-coast is recommended as a proper place for scrofulous children. The children ought to stay there until the signs of scrofula have disappeared and the entire nutrition has been improved. The results obtained in the sanitary stations (vacation colonies) along the sea-shore for scrofulous children have received much favorable comment.

Mountain air has a similarly favorable effect especially when salt water baths are used at the same time; even the plain, pure country air proves beneficial to scrofulous children. Very dry locations and dwellings ought to be selected. The children should remain out of doors as much as possible.

Of great importance for scrofulous children, furthermore, is a suitable course in gymnastics and rubbing-down with cold water. To begin with the water may be 72 deg. but should gradually be reduced to the natural temperature of well water.

Just how far Koch's new method will take the place of former remedies used for scrofula can not be told at present as experiments in this direction are wanting. Nevertheless it will be possible to prevent the dangerous transition of scrofula into tuberculosis and thus save the lives of a great many persons.

Anyone who has informed himself through the foregoing as to the great number of diseases and forms of disease that are directly or indirectly connected with tuberculosis, will now be able to estimate the farreaching import of Koch's discovery. It will now be clear to him that pulmonary consumption constitutes only a part, although a great part of tuberculosis and that there are a great many diseases besides that can now be surely cured, it is hoped, with the aid of Koch's method. But this much should be remembered by everyone that this remedy also acts best and surest during the beginning of a disease. We hope that no one will allow valuable time to slip unimproved; it may easily happen that it is too late for successful treatment. Everyone will be able to recognize the symptoms of diseases, which Koch has taught to cure, from the foregoing complete description, and it is better to apply the remedy once too often than miss the proper time for application.

Koch's first communications relating to the subject have just been published and will be given unabridged in the following pages. As these communications are written for physicians we will add such explanatory notes as are deemed essential for general intelligence.



THE FIRST COMMUNICATION

Relating to a Method to Cure

TUBERCULOSIS,

BY

Prof. R. KOCH, Berlin.

In a lecture, delivered by me several months ago, at the International Medical Congress, I referred to a remedy, which makes animal subjects impervious to the inoculation of Tubercle-bacilli, and in the case of diseased animals, checks the progress of the tuberculous disease. In the meantime experiments have been made with human subjects, about which I will report in the following.

Originally I intended to complete my investigations and especially gain sufficient experience concerning the practical application of the remedy and its production on a larger scale before I published anything concerning it. In spite of all precautions too much has already been published about it, and that distorted and exaggerated, so that I was obliged, in a way, to prevent false conceptions, to give even now a synopsis of the method as far as it has progressed at the time being. Under present circumstances it must necessarily be short and leave unanswered many important questions.

The experiments have been, and are still being made under my direction by Dr. A. Libbertz and Stabsarzt Dr. E. Pfuhl. The necessary subjects and material have been provided by Prof. Brieger from his Polyclinic, Dr. W. Levy in his Private Surgical Clinic, Geheimrath Fraentzel and Oberstabsarzt R. Koehler in the Charite-Hospital, and Geheimrath Herr v. Bergmann in the Surgical University Clinic. To all these gentlemen and their assistants I here tender my heartfelt thanks for their untiring interest which they manifested for this subject and also for the disinterested help and aid which they have offered at all times and without which it would have been impossible for me to make such progress in a few months in this difficult and responsible investigation.

As my work is far from being completed, I can not as yet make any statements relating to the origin and preparation of this remedy and reserve these for some future time.[1]

The curative is composed of a clear brown fluid, which in itself is not perishable, even without special precautionary measures. For use this fluid must be more or less diluted and these dilutions are perishable when made with distilled water; Bacterian vegetation soon develops in them and they become turbid and are no longer fit for use. To prevent this the dilutions must be sterilized through heat and be kept under cotton batting or be prepared with a 5 per cent. phenol solution which is much simpler. Through repeated heating as also through the mixture with the phenol the efficiency of the diluted solution appears to be curtailed after a time and for that reason I have always used solutions as fresh as possible.

The remedy does not act through the stomach; to effect a reliable action it must be applied subcutaneously. For our experiments we have exclusively used a syringe decided upon by myself for bacteriological purposes, which is supplied with a small india-rubber ball and which has no stamp. Such a syringe can be easily kept positively aseptic by rinsing with absolutely pure alcohol and on this we base the fact that not a single abscess has sprung from over a thousand injections.

After trying various parts of the body as places for application we selected the skin of the back between the shoulderblades and in the lumbar region, because at these places the injection was almost painless and caused the least and in most cases no local reaction.

Even at the beginning of our experiments we found that in one particularly important point the human subject was affected by the curative in a way decidedly differing from that of the animal subject generally used, the guinea pig. Therefore another confirmation of the rule for experimentors upon which hardly enough stress can be laid, not to rely upon a like effect upon the human being from the experiments on the animal without further confirmatory inquiry.

Man proved himself much more sensitive to the effects of the remedy than the guinea pig. Up to two cubic centimeters and even more of the undiluted fluid could be injected under the skin of a healthy guinea pig without causing any particularly disparaging effect. In the case of a fullgrown man on the other hand, 25 ccm. are sufficient to produce intense results. In proportion to weight of body therefore 1/1500 of the amount which has no noticeable effect on the guinea pig has a decidedly strong effect on the man.

From an injection that I have made on my upper arm I have experienced the symptoms which arise in man after an injection of 25 ccm., in short they were the following: Three or four hours after the injection a raking pain in the joints, languor, inclination to cough, oppressed breathing, which rapidly increased; in the fifth hour I experienced intense chills which lasted nearly an hour, at the same time nausea, vomiting, increase of the temperature of the body to 39.6 deg. C. After about 12 hours all these affectations ceased. The temperature sank and reached the normal height the next day. Heaviness of the limbs and languor lasted for a few more days, and for the same length of time the place of injection remained red and painful.

The lower limit of effect of the curative for a healthy man is about .01 ccm. (= 1 cubic centimeter diluted with a 100 parts) as numerous trials have shown. The majority reacted on this dose with only light pain in the joints and passing languor. With a few a slight rise in temperature set in, to 38 deg. C. or a trifle higher.

Although there is a marked difference as regards the dose of the curative (according to relative weight of body) between the animal subject and man, an evident resemblance is shown in several other qualities.

The most important of these qualities is the specific action of this remedy on tuberculous processes of whatever kind they may be. I will not relate the effects on the animal subject in this connection, as it would lead too far, but will at once turn to the peculiar effects on tuberculous human beings.

As we have seen, a healthy man reacts but little or not at all on .01 ccm. The same is true of diseased persons, provided they are not tuberculous. But the relations are entirely different with those afflicted with tuberculosis; a marked general and also a local reaction resulted from an injection of the same dose of the remedy (.01 ccm.)[2].

The general reaction consists of an attack of fever, which, beginning mostly with chills, raises the temperature to over 39 deg., often up to 40 deg. and even 41 deg. Other noticeable symptoms are pains in the joints, a tendency to cough, great languor, and often nausea and vomiting. Several times we observed a faint icteric coloring and in some cases the appearance on neck and breast of an exanthema resembling measles. As a rule the attack begins 4-5 hours after the injection and lasts 12-15 hours. In exceptional cases it may begin much later, but then it is not nearly so intense. The patients experience remarkably little weakness from the attack and feel relatively well as soon as it is over, generally better than they did before it came on.

The local reaction can best be observed on those patients whose tuberculose affection is plainly visible, for instance those afflicted with lupus. In them changes take place that prove the specific antitubercular action of the remedy in a most surprising way. The diseased portions of the skin in the face, etc. begin to swell and turn red even before the attack of chills set in, although the injection is made under the skin of the back, a point decidedly remote from the affected parts. The swelling and reddening increases during the fever and can attain a very marked degree so that the lupus-tissue turns reddish brown and necrotic. In the case of more sharply defined lupus centres the more swollen and dark red parts were edged by a white seam nearly a centimeter wide and this again was surrounded by a wide bright red border. The swelling of the diseased parts gradually decreases after the cession of fever and may have entirely disappeared after 2 or 3 days. A serum exudes from these lupus-centres and, drying, forms a crust on them which changes into scabs that fall off in 2-3 weeks and sometimes leave a smooth red scar after a single injection. Generally several injections are necessary to effect a complete removal of the lupose tissue, but of this I will speak further on. It is very important to note that the changes during this process are exclusively limited to the portions of the skin affected by lupus; even the faintest and smallest bits of diseased tissue go through the entire process and become visible on account of their swelling and reddening, while the actual scab-tissue in which the various stages of lupus have been completed remains unchanged.

The observation of the treatment of lupus with the remedy is so instructive and must be so convincing as regards the specific nature of the remedy that every one wishing to occupy himself with the study of this remedy should if possible make his first experiments with lupus.

Less marked, but still apparent to the eye and touch are the local reactions in tuberculosis of the lymphatic glands, of the bones and joints, etc., in which case swelling and increased painfulness, and in the more superficial parts also a reddening can be observed.

The reaction in the inner organs, especially the lungs is removed from our observation unless we consider the increased coughing and expectoration of the patients after the first injection a local reaction. At the same time we must assume that these parts undergo changes directly observed in the case of lupus.

The different forms of reaction described have appeared without exception in previous trials on the dose of .01 ccm. when any form of tuberculosis prevailed in the system, and therefore I trust that I am justified in assuming, that in the future this remedy will constitute an indispensible diagnostic auxiliary. We will be enabled to diagnose in doubtful cases of phthisis even then, when it is impossible to obtain reliable information concerning the nature of the ailment, by the presence of bacilli or elastic fibres in the sputum or by a physical examination. Glandular affectations, hidden tuberculosis of the bones, doubtful tuberculosis of the skin and the like will easily and reliably prove to be such. In case of apparently completed processes of tuberculosis of the lungs or joints it will be possible to show whether the process of the disease is in reality a complete one or establish the existence of centres from which later on the disease may spread like a fire from a live coal in the ashes.

But much more important are the specific qualities of the remedy than the aids it offers for the diagnosis.

While describing the changes, that are caused by hypodermic injections of the remedy, on the parts of the skin affected by lupus, attention was called to the fact that the lupose tissue does not return to its original condition after the swelling and reddening have ceased, but is more or less destroyed and disappears. On some places, as observation teaches, the process is such, that after a single injection the diseased tissues undergo mortification and are cast off as dead matter later on. On other places it seems that a diminution or rather a kind of melting of the tissue is caused, and to effect a complete disappearance a repeated application of the remedy is necessary. As the required histological investigation is wanting, it is impossible at the present time to state with certainty how this result is brought about. Only this much is known that it is not a destruction of the tubercle bacilli, but that only the tissue containing the tubercular bacilli is affected by the application of the remedy. In this, as the visible swelling and reddening show, greater circulatory derangements are caused and with these vital changes in the assimilation which result in a more or less rapid and thorough mortification of the tissue according to the manner in which the remedy is allowed to act.

To make a short repetition, the remedy therefore does not destroy the tubercle bacilli, but the tuberculous tissue; on dead tissue, for instance, gangrenous cheesy matter, necrotic bones, etc., it does not act; nor on tissue that has undergone mortification through the action of the remedy itself. Living bacilli can still linger in such dead masses of tissue, which are either cast out with the necrotic tissue, or may possibly migrate under special conditions into the adjoining living tissue.

This quality of the remedy must be particularly observed, if its full specific action is to be obtained. Therefore we must first cause the mortification of the tuberculous tissue, and then effect its removal as soon as possible, for instance, by means of a surgical operation; but where this is impossible and the excretion by the organisms themselves is necessarily slow, we must attempt by continued application of the remedy to protect the endangered living tissue from the immigration of the parasites.

As the remedy acts only on living tissue and causes mortification of tuberculous tissue, we can readily explain another exceedingly peculiar property of the remedy, namely, that it can be given in rapidly increased doses. This may apparently be explained as being based on inurement. But noting that in about three weeks the dose may be increased to 500 times the strength of the first one, it is unquestionably something more than habit, as we know of nothing analogous confirming such a rapid and farreaching adaptation to any powerful drug.

This fact can rather be explained thus: in the beginning there is an abundance of living tuberculous tissue and only a minute quantity of the effective substance is sufficient to cause a strong reaction; through each injection a certain quantity of this responsive tissue disappears, and then relatively larger doses are required to cause the same degree of reaction as before. Aside from this adaptation may assert itself within certain limits. As soon as the patient is treated with such increased doses, and that he reacts no more than one not afflicted with tuberculosis, we may assume that all the reactive tuberculous tissue is dead. It is then only necessary to continue the treatment at intervals and with gradually increased doses as long as any bacilli remain in the system, to protect the patient from a new infection.

It remains to be learnt in the future whether this conception and the deductions based thereon are correct. For the present I have directed the manner of application of the remedy on this basis, which in our experiments resulted as follows:

To begin again with the simplest case, namely lupus, we injected the full dose of .01 ccm. in nearly all such patients to begin with, and allowed the reaction to take its full course, after 1-2 weeks we again injected .01 ccm. and so forth until the reaction became less and less and finally ceased. In the case of two patients with facial lupus three respectively four injections in this manner resulted in a clean, smooth scar in place of the affected parts; the remaining patients of this kind have also improved in a measure proportioned to the time of treatment. All the patients have suffered from their afflictions for years and have been treated by various methods without success.

Tuberculosis of the glands, bones and joints has been treated in a very similar manner, as in these cases larger doses were applied at longer intervals. The result was the same as with lupus, a rapid cure in the lighter and milder cases and a slowly progressing improvement in the severer ones.

With the majority of our patients, those suffering from pulmonary consumption, the conditions are somewhat different, patients with decided pulmonary tuberculosis are very much more responsive to this remedy, than those afflicted with surgical tubercles. We were forced to reduce the quantity of the first dose of .01 ccm. as prepared for the phthisicist, and we found that as a rule he reacted strongly on a dose of .002 and even .001 ccm., but that the quantity could be rapidly increased from this low initial dose to that which could be easily tolerated by the other patients. We generally proceeded in such a manner that the patient at first received an injection of .001 ccm. and if a rise in the temperature set in this dose was repeated once daily until the reaction ceased. Only then the dose was increased to .002 ccm. and applied till the reactions failed to appear. And so forth, always increasing the dose only .001 or at the most .002 up to .01 ccm. and higher. This mild procedure seemed to me imperative, especially with such patient as were in a weak and feeble condition. Proceeding in the manner just described we can easily attain the application of very light doses with but slight attacks of fever and hardly perceptible to the patient. Some of the stronger consumptives were treated with larger doses from the beginning, partly with a forced increase in the dosing when it seemed as though the favorable result was obtained in a correspondingly shorter time. The action of the remedy on the phthisicist generally seemed to be such that cough and expectoration increased somewhat after the first injection, then gradually diminished and in favorable cases disappeared entirely; the sputum lost its purulent nature and became slimy. The number of bacilli as a rule did not decrease until the sputum had attained a phlegmy appearance (only such patients were selected for these experiments in whose expectorations bacilli were contained). They entirely disappeared temporarily, but were again met with from time to time until the expectoration had completely stopped. At the same time the night-sweats left off, and the patients improved in appearance and gained in weight. All patients treated in the first stages of phthisis were freed from all symptoms of disease in the course of 4-6 weeks so that they could be considered as cured. Even patients with cavities not too large were considerably improved and nearly healed. But in the case of such consumptives, whose lungs contained many and large cavities no objective improvement could be marked, although the expectoration diminished and they appeared to feel much better. I am inclined to assume on the basis of these experiences, that the earliest stages of phthisis can with certainty be cured by this remedy.[3] This may also hold good in cases that are not too far advanced.

In exceptional cases only will pulmonary consumptives, with large cavities, derive continued benefits through the application of the remedy, when other complications exist, for instance, the penetration of other supurative micro-organisms, irremovable pathological changes in other organs, etc. Even such patients were in most cases temporarily improved. It must follow that even in them the original process of the disease, tuberculosis, is influenced in the same manner by this remedy as in other patients, but that it is impossible to remove the gangrenous masses of tissue and also the secondary supurative processes. Naturally we are led to think that perhaps in some of these severe cases cures may be effected by means of a combination of this healing process together with surgical aid (after the manner of operating empyema) or some other curative means. I would not advise anyone however, to apply this remedy without discrimination in every case of tuberculosis. The simplest mode of application will certainly be required in treating the first stages of phthisis and simple surgical affections, but in all other forms of tuberculosis medical science should draw on all its resources and individualize carefully to supplement and sustain the action of the remedy. In many cases I have had the decided impression that the attendance to and nursing of the patient was of no little influence on the curative process, and therefore I would prefer the application of the remedy in suitably adapted institutions, where a close observation of the patient and the adequate attention to them is possible, to the ambulant or home treatment. No estimate can at present be made as to the extent in which a profitable combination can be made between this new method to cure and those modes of treatment that have thus far been considered beneficial, the application of mountain climate, the free air treatment, specific nourishment, etc.; but I trust, that these remedial factors will be of considerable use in conjunction with the new method in many cases, especially the severe and neglected as also in the convalescent stages.[4]

The nucleus of this new curative method lies in the earliest possible application. The proper objects of treatment ought to be the first stages of phthisis, because here the remedy can fully develop its curative qualifications. Therefore it is of vital importance, more so in the future, than it has been in the past, that practical physicians employ all possible means to diagnosticate phthisis in as early a stage as possible. Until lately the finding of tubercle bacilli existing in the sputum was rather considered as an interesting incidental evidence, which, although it insured the diagnosis, was of no further benefit to the patient and therefore was only too often omitted, as I have only lately discovered in numerous cases of phthisis which had passed through the hands of several physicians without having their sputum examined once. This must be different in the future. Any physician who fails to search for tubercle bacilli in the sputum, to establish phthisis in as early a stage as possible, commits gross negligence toward his patient, because his life may depend on this diagnosis and the specific treatment which has hurriedly been introduced on this basis. In doubtful cases the physician should gain certainty as to the existence or absence of tuberculosis through a trial injection.

Only then will the new mode of treatment truly become a panacea for suffering mankind when that period is reached, where all cases of tuberculosis are treated in as early a stage as possible, to prevent the development of neglected severer cases which have heretofore formed a continual unlimited source of new infection.

In conclusion I would remark, that I have intentionally omitted all numerical statistics and descriptions of individual cases in this communication, because the physicians to whose material the patients provided for our experiments belonged, have themselves undertaken the description of their respective cases and I did not wish to anticipate them in an objective representation of their observations.

FOOTNOTES:

[1] Physicians who wish to experiment with the remedy, can get the same of Dr. A. Libbertz (Berlin, N. W., Lueneburgerstrasse 28 II.), who has undertaken the production of the remedy with Dr. Pfuhl's and my assistance. But I must state that the present stock is very limited, and that larger quantities can only be disposed of at the end of several weeks.

[2] We gave children of 3-5 years of age one tenth of this dose, that is .001 and very weak children .0005 ccm. and obtained a strong though not alarming reaction.

[3] This statement is necessarily confined in so far as we have no conclusive experiences, and can not have at present, that show whether the cure is a permanent one, recidivations of course are not excluded for the present. But we may assume that these will be removed as easily and quickly as the first attack.

On the other hand it is possible from analogy with other infectious diseases that those who are once cured become permanently exempt. This must also be considered an open question for the present.

[4] It was impossible to collect data referring to cerebral-laryngeal-and miliary-tuberculosis, as we did not have sufficient material.



Explanatory Notes.

Koch states that he can not at the present make any statement about the origin and preparation of the remedy, as his labors are not yet completed.

We may assume that it is very probably a substance that corresponds in a way to the lymph used for vaccination. As vaccine lymph represents variolous poison greatly reduced in strength, as the remedy for hydrophobia is composed of a substance which is weakened hydrophobic poison, so Koch probably obtains his remedy for tuberculosis by artificially reducing the tuberculous poison by means of various processes.

A number of years ago it has been tried with syphilis in a similar way to obtain a substance that would not only cure syphilis but would also guard against infection from it. At that time however the experiment was not successful.

From several intimations I am inclined to believe that Koch was successful in finding a way in which a substance may be produced for contagious diseases, a substance that cures these diseases and also protects from infection. It is not impossible, since Jenner found the vaccine virus, Pasteur the hydrophobic lymph and now Koch the tubercle lymph.

To be sure there is this difference for the present between the substances named, that the vaccine virus only protects healthy person from infection by small pox but it does not cure those sick, while the hydrophobic lymph and tubercle lymph cure the afflicted. However Koch seems to believe that his tubercle lymph has a certain power of producing immunity.

According to Koch, his remedy, consisting of a brownish liquid, is easily perishable as soon as it is diluted with water; he recommends the preparation of the dilution of the remedy with a 5 per cent. phenol solution. Phenol is equivalent to carbolic acid. The dilution of the remedy for use must be considerable, as only small quantities of the same are used.

Koch tells us that his remedy does not act through the stomach, that is taken in through the mouth. On one hand it may be that this is due to the extremely small quantities necessary for an effect, on the other hand and principally all the substances probably act only when they are directly applied and brought in contact with the circulation of the blood.

For a long time small syringes with fine needle points were used to inject strong acting drugs under the skin. This is done in a measure to have a guarantee of a sure effect which is not had by giving through the mouth. For instance, it is known that emetics given through the mouth often remain without results; if however the emetic apomorphine is injected anywhere under the skin, vomiting surely follows within a very short time. It is well known that morphine is injected under the skin in preference to taking it through the mouth as its action as a pain killer is much prompter.

Koch's liquid can also be injected under the skin with the aid of a so-called Pravaz syringe. Koch uses a somewhat differently formed syringe. The result remains the same, no matter what kind of syringe is used.

At the same time it makes but little difference, on what part of the body the injection is made, as the fluid injected under the skin is distributed at once over the entire system. Koch chose the skin of the back between the shoulderblades and the loins because here the injection could be made without causing pain or inflammation.

The production of the liquid must be attended with great difficulties as Koch plainly remarks that his stock at present is very limited and he can only furnish larger quantities at the end of several weeks. The price of a small bottle to be 25-30 Marks about 6-8 Dollars.

The human being is much more sensitive to Koch's remedy than the guinea pig, which is commonly used for experiments of this kind. It seems that no experiments have as yet been made with other animals.

Koch has tried the remedy on himself and has passed through all the symptoms of a poisoning. He certainly injected into his arm a considerable quantity of the liquid; twenty-five times as much as he injected in his patients.

But here also there is a difference. In sick people much smaller quantities act than in the healthy. One cubic centimeter of the liquid has hardly any effect on a healthy person, but quite a marked one on those afflicted with tuberculosis.

In the case of the latter one cubic centimeter produces about the same symptoms as twenty-five times the quantity would in a healthy person. The same must also be considered as symptoms of poisoning; but they are only of short duration and are accompanied with magnificent success.

Of all diseases based on tuberculosis only ringworm or lupus is perceivable by the eye, as it is a disease of the skin, all other tuberculous diseases take their course in the internal parts of the body, and therefore are not perceptible to the eye. The symptoms that follow an injection of Koch's liquid can be best observed in the case of lupus.

Koch therefore selected for his first illustration patients afflicted with lupus that is ringworm. Even a few hours after the injection the first perceptible changes begin to show in the diseased parts. These begin to swell and redden; in other words an inflammation is caused, through which the diseased tissue is obviously brought to mortification. Soon the inflammation stops. The gangrenous tissue changes into crusts or scabs which drop off in a short time and the patient is cured of his ringworm.

Koch places particular importance on the fact that the inflammation is restricted to the diseased parts only, and that it does not attack sound and healthy parts. Even the smallest otherwise invisible knots are made perceptible through the inflammation.

We have similar illustrations for this specific action of Koch's remedy for lupus (ringworm). So for instance a syphilitic ulcer on the thigh may be cured in a few days with iodide of potassium. In a similar manner a morbidly enlarged spleen may be reduced to the normal size by taking quinine.

The observation is very interesting indeed, as it may be shown whether a person is tuberculous in any organ or not by the injection of .01 ccm. In case he is tuberculous the poisoning symptoms appear in a marked degree; if he is not, hardly any effect is noticeable.

Although we have had excellent methods for a long time to detect pulmonary consumption, although Koch added the discovery of the tubercle bacilli, it occasionally happens that the disease can not be recognized in its beginning stages, because its progress is too slight. Now the reaction following an injection is to be the deciding medium. Also with other tuberculous affections physicians will welcome this diagnostic auxiliary, for in the beginning of the same it often happens that no certain diagnosis could be made and valuable time was lost.

We must call particular attention to the further statements of Koch, that through his remedy the tubercle bacilli are not killed. With this it is admitted that the remedy will not be able to effect cures, without any more ado, yes, even the tubercle bacilli may continue to infect parts of the body even in spite of the action of the remedy.

Therefore the application of Koch's remedy only, is not sufficient to effect a cure. Provision must be made to remove the gangrenous tissue from the body as rapidly as possible, because it contains the still living tubercle bacilli. As a rule surgical aid is necessary to remove the mortified tissue. Where this is impossible Koch advises the continued application of the remedy to protect the endangered living tissue from the re-immigration of the tubercle bacilli. Koch thereby believes that he can protect the tissue, perhaps in the manner as vaccination protects from small pox.

The rapid increase in the quantity of the remedy applied in the course of time is something that has no parallel. Koch gives an explanation, but leaves it to the future to be confirmed. We have no previous instance in case that his explanation should prove correct. Reasoning from analogous application of our remedy, we are led to assume that smaller quantities of the substance would suffice to cause mortification of the remaining tuberculous tissue. Koch on the other hand uses larger and larger doses to reach a result. He admits inurement to the remedy within certain limits only.

Koch has made a difference between pulmonary consumptives and those suffering from tuberculosis of the bones and joints, etc. He was able to inject larger quantities in the latter than the former, for the quantity injected in the case of pulmonary consumptives was .001 ccm.; in other tuberculous cases .01 ccm.

Koch selected pulmonary consumptives for his experiments, whose sputum contained tubercle bacilli, so as to make no error in the diagnosis, and to ascertain by killing the bacilli contained in the sputum, whether the diseased tend toward restoration. As the remedy does not kill the bacilli, so a diminution of the bacilli can only be obtained in that manner, that the tissue of the lungs undergoes certain changes, which cause its properties to be such, that the bacilli are no longer able to exist or propagate in them. Then a so-called immunity results which we know of in other similar diseases. We know that anyone who has had the measles or scarlet fever rarely is again attacked by the same, as a rule he is permanently proof against them.

In the same way as vaccination protects from small pox, an injection of Koch's remedy acts against pulmonary consumption. Koch makes a cautious statement:

"On the other hand it is possible, from analogy with other infectious diseases that those who are once cured become permanently exempt."

Koch reaches this result, that beginning phthisis can with certainty be cured with his remedy. On the other hand, advanced consumptives, in whose lungs large cavities already exist, may possibly be improved but can not be cured. However he provokes the idea, that perhaps his method of treatment together with a surgical operation, that removes all gangrenous matter from the lungs, may yet have beneficial results in the end. The idea is not entirely new to treat lung diseases with the aid of surgery; unfortunately the operations have heretofore been thought too risky. Perhaps we will now have a new branch in operative technic, surgery of the lungs. Koch advises to conduct this lung surgery after the manner of operating empyema. This is an operation performed in the case of suppurative pleurisy to remove the pus from the pleural cavity. This operation has been successfully carried out for a long time.

Koch makes it of especial importance, that while treating consumption with the new remedy, the general attendance and nursing is not to be neglected. Koch also calls attention to what has been said before, that the general hygienic factors, good hospital treatment, mountain climate, etc., will never be dispensed with, on the contrary will be indispensible to the furtherance of cure.

In conclusion Koch again remarks that brilliant results are only promised in the early stages of pulmonary consumption (phthisis). Physician and patient must move all levers as to the existence or non-existence of tuberculous diseases.

Then those daily pictures of extreme wretchedness from consumption will be a thing of the past. Then the danger of contagion will be lessened resulting from the decrease of the number of tuberculous persons and of the tubercle-bacilli, and perhaps it will soon be possible to name the day on which with the last tubercle-bacillus the ravaging pest, tuberculosis, will be extirpated.

- Transcriber's Note: Inconsistent use of develops/developes, and centres/centers has been retained as in the original. -

THE END